Impact of Antenatal Care Modifications on Gestational Diabetes Outcomes During the COVID-19 Pandemic

BACKGROUND

Many of the adverse outcomes of gestational diabetes mellitus (GDM) are linked to excessive fetal growth, which is strongly mediated by the adequacy of maternal glycemic management. The COVID-19 pandemic led to a rapid adoption of virtual care models. We aimed to compare glycemic management, fetal growth, and perinatal outcomes before and during the COVID-19 pandemic.

METHODS

A retrospective cohort study was conducted between 2017 and 2020. Singleton pregnancies complicated by GDM were included in the study. The cohort was stratified into "before" and "during" COVID-19 subgroups, using March 11, 2020, as the demarcation time point. Women who began their GDM follow-up starting March 11, 2020, and thereafter were allocated to the COVID-19 era, whereas women who delivered before the demarcation point served as the pre-COVID-19 era. The primary outcome was the rate of large-for-gestational-age (LGA) neonates. Secondary outcomes included select maternal and neonatal adverse outcomes.

RESULTS

Seven hundred seventy-five women were included in the analysis, of which 187 (24.13%) were followed during the COVID-19 era and 588 (75.87%) before the COVID-19 era. One hundred seventy-one of the 187 women (91.44%) followed during COVID-19 had at least 1 virtual follow-up visit. No virtual follow-up visits occurred before the COVID-19 era. There was no difference in the rate of LGA neonates between groups on both univariate (5.90% vs 7.30%, p=0.5) and multivariate analyses, controlling for age, ethnicity, parity, body mass index, gestational weight gain, chronic hypertension, smoking, and hypertensive disorders in pregnancy (adjusted odds ratio [aOR] 1.11, 95% confidence interval [CI] 0.49 to 2.51, p=0.80). In the multivariate analysis, there was no difference in composite neonatal outcome between groups (GDM diet: aOR 1.40, 95% CI 0.81 to 2.43, p=0.23; GDM medical treatment: aOR 1.20, 95% CI 0.63 to 2.43, p=0.5).

CONCLUSIONS

After adjusting for differences in baseline variables, the combined virtual mode of care was not associated with a higher rate of LGA neonates or other adverse perinatal outcomes in women with GDM. Larger studies are needed to better understand the specific impact of virtual care on less common outcomes in pregnancies with GDM.

Validity of Alternative Claims-based Algorithms for Type 1, Type 2, and Gestational Diabetes in Pregnancy

OBJECTIVE

Our aim in this study was to evaluate the accuracy of alternative algorithms for identifying pre-existing type 1 or 2 diabetes (T1DM or T2DM) and gestational diabetes mellitus (GDM) in pregnant women.

METHODS

Data from a clinical registry of pregnant women presenting to an Edmonton diabetes clinic between 2002 and 2009 were linked and administrative health records. Three algorithms for identifying women with T1DM, T2DM, and GDM based on International Classification of Diseases---tenth revision (ICD-10) codes were assessed: delivery hospitalization records (Algorithm #1), outpatient clinics during pregnancy (Algorithm #2), and delivery hospitalization plus outpatient clinics during pregnancy (Algorithm #3). In a subset of women with clinic visits between 2005 and 2009, we examined the performance of an additional Algorithm #4 based on Algorithm #3 plus outpatient clinics in the 2 years before pregnancy. Using the diabetes clinical registry as the "gold standard," we calculated true positive rates and agreement levels for the algorithms.

RESULTS

The clinical registry included data on 928 pregnancies, of which 90 were T1DM, 89 were T2DM, and 749 were GDM. Algorithm #3 had the highest true positive rate for the detection of T1DM, T2DM, and GDM of 94%, 72%, and 99.9%, respectively, resulting in an overall agreement of 97% in diagnosis between the administrative databases and the clinical registry. Algorithm #4 did not provide much improvement over Algorithm #3 in overall agreement.

CONCLUSIONS

An algorithm based on ICD-10 codes in the delivery hospitalization and outpatient clinic records during pregnancy can be used to accurately identify women with T1DM, T2DM, and GDM.

Temporal Trends in Type 1, Type 2, and Gestational Diabetes in Pregnancy: Impact of Rural Residence, Ethnicity, and Material Deprivation

OBJECTIVE

Our aim in this study was to implement a newly validated algorithm to identify pregnant women with type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), and gestational diabetes mellitus (GDM), and to identify temporal trends in rates over the last decade. We also compared obstetric and neonatal outcomes of pregnancies with and without diabetes mellitus (DM).

METHODS

Among women with live births between 2005 and 2018 in Alberta, we calculated yearly rates of T1DM, T2DM, and GDM, overall, and stratified by ethnicity, urban or rural residence, material deprivation score, and maternal age.

RESULTS

Between 2005 and 2018, GDM rates increased from 42.3 to 101.8 per 1,000 deliveries (p<0.0001), T2DM rates increased from 2.6 to 6.4 per 1,000 deliveries (p<0.0001), whereas T1DM remained constant at 3.0 per 1,000 deliveries each year (p=0.4301). Higher GDM and T2DM rates were observed among Chinese and South Asian women, respectively, and among women who were materially deprived and living in urban areas. Women with T2DM were older and had the highest rates of pre-existing hypertension (16%). In contrast, women with T1DM were younger and had the highest rates of gestational hypertension (12%), pre-eclampsia (12%), and cesarean section deliveries (62%). Children of women with T1DM had the highest rates of large for gestational age (46%), neonatal hypoglycemia (41.1%), respiratory distress syndrome (7.7%), and jaundice (29.3%).

CONCLUSIONS

Diabetes-in-pregnancy rates have more than doubled over the last decade, driven primarily by increases in GDM and T2DM. These trends may have significant implications for the future health of mothers and children in Alberta.

The Contribution of Gestational Diabetes to Diabetes Risk Among First Nations and Non-First Nations Women in Saskatchewan: Results From the DIP: ORRIIGENSS Project

OBJECTIVES

Our aim in this study was to determine the risk for diabetes mellitus (DM) among Saskatchewan First Nations (FN) and non-FN women with prior gestational DM (GDM).

METHODS

Using Ministry of Health administrative databases, we conducted a retrospective cohort study of DM risk by GDM occurrence among FN and non-FN women giving birth from 1980 to 2009 and followed to March 31, 2013. We determined frequencies and odds ratios (ORs) of DM in women with/without prior GDM after stratifying by FN status, while adjusting for other DM determinants. Survival curves of women until DM diagnosis were obtained by prior GDM occurrence and stratified by ethnicity and total parity.

RESULTS

De-identified data were obtained for 202,588 women. Of those who developed DM, 2,074 of 10,114 (20.5%) had previously experienced GDM (811 of 3,128 [25.9%]) FN and 1,263 of 6,986 [18.1%] non-FN). Cumulative survival of women with prior GDM until DM was higher for FN than for non-FN women (82% vs 46%), but prior GDM was a stronger predictor of DM within the non-FN cohort (prior GDM vs no GDM: OR, 9.64 for non-FN; OR, 7.05 for FN). Finally, higher total parity interacted with prior GDM to increase DM risk in both groups. With prior GDM and parity ≥3, 93% of FN and 57% of non-FN women subsequently developed DM.

CONCLUSIONS

GDM is a leading determinant of T2DM among FN and non-FN women, amplified by higher parity. This contributes to earlier onset diabetes, affecting subsequent pregnancies and increasing risk for chronic diabetic complications. It may also factor into higher type 2 DM rates observed in FN women compared with men.

Effects of High-dose Folic Acid Supplementation on Maternal/Child Health Outcomes: Gestational Diabetes Mellitus in Pregnancy and Insulin Resistance in Offspring

OBJECTIVES

The purpose of this study was to evaluate the effects of maternal high folic acid (FA) supplementation during pregnancy on glucose intolerance in dams and insulin resistance in offspring.

METHODS

Wistar female rats (n=18) were mated and randomly divided into 3 groups: a control group and 2 experimental groups. Three different feeding protocols were administered during pregnancy: control group, 2 mg/kg FA (recommended level FA supplementation); experimental 1 group, 5 mg/kg FA (tolerable upper intake level of FA supplementation [ULFolS]); and experimental 2 group, 40 mg/kg FA (high FA supplementation [HfolS]). All dams were fed the same FA content diet (2 mg/kg FA) during the lactation period. An oral glucose tolerance test was performed on day 16 of pregnancy. After the lactation period, body weight and food intake of 36 pups were monitored. Dams were euthanized at the end of the lactation period and half of the pups were euthanized at the end of week 7 and the others at the end of week 12. Serum FA, homocysteine, vitamin B₁₂, insulin, glucose, interleukin-6, tumor necrosis factor-alpha, glycated hemoglobin (A1C), and adiponectin levels of mothers and pups were evaluated. The homeostatic model of insulin resistance (HOMA-IR) was used to determine insulin resistance in dams and offspring.

RESULTS

According to glucose tolerance test results of dams, blood glucose values at minutes 0, 60, 90, and 120 for the HFolS group were significantly higher compared with the control group (p<0.05). The A1C level in HFolS dams was significantly higher than in the control group (p<0.05). The mean birthweight of the pups in the HFolS group was significantly higher than that of control pups (p<0.05). HOMA-IR values for control and HFolS offspring were similar at weeks 7 and 12 and higher than in ULFolS offspring (p>0.05).

CONCLUSIONS

It was determined that high doses of FA exposure during pregnancy might be effective in the development of glucose intolerance in dams and insulin resistance in offspring in this study.

Validation of Algorithms to Identify Gestational Diabetes From Population-level Health-care Administrative Data

OBJECTIVES

Our aim in this study was to determine the test characteristics of algorithms using hospitalization and physician claims data to predict gestational diabetes (GDM).

METHODS

Using population-level health-care administrative data, we identified all pregnant women in Ontario in 2019. The presence of GDM was determined based on glucose screening laboratory results. Algorithms using hospitalization records and/or physician claims were tested against this "gold standard." The selected algorithm was applied to administrative data records from 1999 to 2019 to determine GDM prevalence in each year.

RESULTS

Identifying GDM based on either a diabetes mellitus code on the delivery hospitalization record, OR at least 1 physician claim with a diabetes diagnosis code with a 90-day lookback before delivery yielded a sensitivity of 95.9%, a specificity of 99.2% and a positive predictive value of 87.6%. The prevalence of GDM increased from 4.2% of pregnancies in 1999 to 12.0% in 2019.

CONCLUSION

Algorithms using hospitalization or physician claims administrative data can accurately identify GDM.

Patient-reported Benefits and Limitations of Mobile Health Technologies for Diabetes in Pregnancy: A Scoping Review

OBJECTIVES

For women with pre-existing and gestational diabetes, pregnancy involves specialized and intensive medical care to optimize maternal and infant outcomes. Medical management for patients with diabetes in pregnancy typically occurs via frequent face-to-face outpatient appointments. COVID-19-induced barriers to face-to-face care have identified the need for high-quality, patient-centred virtual health-care modalities, such as mobile health (mHealth) technologies. Our aim in this review was to identify the patient-reported benefits and limitations of mHealth technologies among women with diabetes in pregnancy. We also aimed to determine how the women's experiences aligned with the best practice standards for patient-centred communication.

METHODS

The framework presented by Arksey and O'Malley for conducting scoping reviews, with refinements by Levac et al, was used to guide this review. Relevant studies were identified through comprehensive database searches of MEDLINE, Embase, Emcare and PsycINFO. Thomas and Harden's methods for the thematic synthesis of qualitative research in systematic reviews guided the synthesis of patient-reported benefits and limitations of mHealth technology.

RESULTS

Overall, 19 studies describing the use of 16 unique mHealth technologies among 742 women were included in the final review. Patient-reported benefits of mHealth included convenience, support of psychosocial well-being and facilitation of diabetes self-management. Patient-reported limitations included lack of important technological features, perceived burdensome aspects of mHealth and lack of trust in virtual health care.

CONCLUSIONS

Women with diabetes report some benefits from mHealth use during pregnancy. Codesigning future technologies with end users may help address the perceived limitations and effectiveness of mHealth technologies.

An Evaluation of Virtual Care for Gestational Diabetes Using the Quadruple Aim Framework: Assessment of Patient and Provider Experience, Cost and Clinical Outcomes

OBJECTIVE

Our aim in this study was to evaluate the impact of virtual care for gestational diabetes mellitus (GDM) in the context of the COVID-19 pandemic.

METHODS

This multiple methods program evaluation used the Quadruple Aim Framework. The impact on patient experience, cost and provider satisfaction was assessed using surveys and interviews. Chi-square and Poisson statistics were used to compare clinical outcomes before (April 2019 to February 2020) and after (May 2020 to March 2021) the shift to virtual care.

RESULTS

Patient experience surveys were completed by 85 women. Most of them rated their virtual care experience as good or excellent (93%), with a preference for continued virtual visits in the future (84%). Most respondents felt virtual care saved them money (93%) and time (98%). Six health-care providers at the Diabetes in Pregnancy Clinic were interviewed and all believed the switch to virtual care was largely positive. Overall, interview transcripts revealed that health-care providers were happy with the transition, although nurses initially perceived an increased workload. There were no significant differences in rates of cesarean section procedures, macrosomia, neonatal intensive care unit admissions or the proportion of appointments at which insulin was initiated between in-person and virtual care patient outcomes. There was a decreased proportion of missed appointments after the switch to virtual care (6.15% vs 1.21%, p<0.0001).

CONCLUSIONS

There has been high patient and provider satisfaction with virtual GDM care, with no difference in clinical outcomes and fewer missed appointments. Virtual GDM care should remain an option in the future.

Incidence of maternal and fetal outcomes in women with gestational diabetes

INTRODUCTION

Gestational diabetes mellitus (GDM) is associated with both maternal and fetal complications related to maternal hyperglycemia.

AIM

The aim of the study was to describe the incidence of maternal and fetal complications associated with GDM in a reference maternity hospital in the Tunis (2019-2020).

METHODS

We conducted a prospective longitudinal descriptive and analytical study including 220 patients followed for GDM at the research unit «Diabetes and pregnancy» of the C department of the National Institute of Nutrition of Tunis. The patients were followed during pregnancy and until post partum, for a period of 18 months (July 2019-December 2020). The patients were divided into two groups Group1(G1) including women treated with insulin therapy (n=68) and Group 2(G2) including women treated with diet only (n=152).

RESULTS

In the current study, 63,6% of patients delivered by cesarean section and 5% developed gestational induced hypertension. Neonatal outcomes were dominated by macrosomia (13.5%) and transient respiratory distress (11.4%). Insulin-treated women had a higher incidence of gestational induced hypertension (G1:11,9% versus G2: 2,1%;p=0,03). There was no significant difference between the two groups in the incidence of fetal outcomes including macrosomia (G1:17.6% versus G2:11.2%; p=0.203),transient respiratory distress (G1:11.8% versus G2: 10.5%; p=0.781) and prematurity (G1:7.4% versus G2:4.6%; p=0.452).

CONCLUSION

Our study showed that Insulin-treated women had a higher incidence of gestational induced hypertension. However, there was no significant difference between the two groups in the incidence of fetal complications.

Congenital Anomalies of the Kidney and Urinary Tract (CAKUT): An Emerging Relationship With Pregestational Diabetes Mellitus Among First Nations and Non-First Nations People in Saskatchewan-Results From the DIP: ORRIIGENSS Project

OBJECTIVES

Because congenital anomalies of the kidneys and urinary tract (CAKUT) represent a frequent cause of end stage renal disease (ESRD) in the young, we explored the epidemiology of CAKUT and the role of diabetes in pregnancy.

METHODS

This was a retrospective cohort study of CAKUT, by maternal diabetes status, from among all 1980‒2009 births in Saskatchewan First Nations (FN) and non-First Nations (non-FN) people. We determined frequencies, predictors and complications of CAKUT, as well as cumulative survival (to 2014) of affected persons until ESRD and death.

RESULTS

Of the 411,055 babies (204,167 mothers) in the Saskatchewan maternal-infant database, 2,540 had CAKUT (391 FN and 2,149 non-FN). Overall annual CAKUT incidence was 0.63% for non-FN and 0.57% for FN (p=0.082), but 5-year CAKUT incidence only increased among FN (0.40% in 1980‒1984 and 0.76% in 2005‒2009, p<0.0001) and was highest among offspring of FN mothers with pregestational diabetes (pre-G/DM) (0% before 1995, 2.51% in 2000‒2004 and 1.66% in 2005-2009). Pre-G/DM, but not gestational diabetes mellitus (GDM), was an independent predictor of CAKUT in non-FN (odds ratio, 1.79; 95% confidence interval, 1.20 to 2.69), and in FN interacting with maternal history of stillbirth (odds ratio, 7.90; 95% confidence interval, 1.14 to 54.6). ESRD was >100-fold more likely among offspring with CAKUT compared with all other offspring and was responsible for 40% of ESRD cases in young FN and non-FN people.

CONCLUSIONS

In Saskatchewan, pre-G/DM is an emerging cause of CAKUT, accounting for 40% of ESRD cases in FN/non-FN children and young adults. Because pre-G/DM‒related CAKUT is potentially preventable with optimal glycemic management, increased recognition of this serious complication is required.

Greater Nutritional Risk Scores in 2-Year-Old Children Exposed to Gestational Diabetes Mellitus In Utero and Their Relationship to Homeostasis Model Assessment for Insulin Resistance at Age 5 Years

OBJECTIVES

Exposure to gestational diabetes mellitus (GDM) in utero may impact nutritional intake and lifestyle habits in early childhood. However, it is unclear whether nutritional status predicts greater risk for metabolic disturbances, such as insulin resistance (IR). The primary objectives were: 1) to determine parent-reported nutritional risk scores in 2-year-old children born to women with and without GDM and 2) to assess whether these scores predict IR in 5-year-old children.

METHODS

Children exposed (n=34) and unexposed (n=46) to GDM were screened at 2 years of age using the Toddler version of the Nutrition Screening Tool for Every Preschooler (NutriSTEP). At a 5-year follow up, IR was assessed using the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR).

RESULTS

Total NutriSTEP scores ranged from 6 to 33, with higher scores indicating greater risk. After controlling for infant birthweight, sex of the child, child ethnicity, maternal age at time of pregnancy, breastfeeding status and maternal prepregnancy body mass index, average NutriSTEP scores were higher in children exposed to GDM compared with those unexposed (13.8±1.1 vs 11.2±1.1, p=0.03). NutriSTEP scores at 2 years emerged as a positive independent predictor of HOMA-IR at 5 years. For each unit increase in NutriSTEP score, suggesting greater nutritional risk, we saw a 0.48 (95% confidence interval, 0.17 to 0.80; p=0.003) increase in score on the HOMA-IR.

CONCLUSIONS

Parent-reported nutritional risk is greater in GDM-exposed children, and these nutritional behaviours developed during the first years of life may predispose to metabolic disturbance in early childhood.

Barriers to, and Facilitators of, Lifestyle Changes to Prevent Gestational Diabetes: An Interpretive Description of South Asian Women and Health-Care Providers Living and Working in Southern Ontario, Canada

OBJECTIVES

People of South Asian ancestry are the fastest growing non-Caucasian ethnic group in Canada and are at high risk for developing type 2 diabetes and coronary heart disease. Pregnant South Asian women have a 2-fold increased risk of developing gestational diabetes, which increases their risk of type 2 diabetes and coronary heart disease. The specific objectives of this study were to explore the perceptions of health behaviours (diet and physical activity) during pregnancy in the South Asian community.

METHODS

We used interpretive description to further understand the cultural and contextual factors that influence the knowledge, attitudes and practices of diet and physical activity of South Asian women of childbearing age and those who provide health care to this group.

RESULTS

Two major themes that emerged from the perspectives of 10 South Asian pregnant women included: (1) importance of considering an individual's locus of control; and (2) support (emotional and information exchange) from family, friends and health-care providers. Two major themes identified by the 11 health-care providers were: (1) cultural awareness in caring for South Asian women during pregnancy; and (2) clinic management, logistics and resources. A common theme for both South Asian pregnant women and health-care providers was the importance of considering the cultural landscape in relation to how knowledge is obtained, shared and valued.

CONCLUSION

A better understanding of these cultural underpinnings may support the development of interventions tailored for pregnant South Asian women and their health-care providers.

Association Between Gestational Diabetes and Mental Illness

The rates of both gestational diabetes mellitus (GDM) and mental illness in pregnancy are rising. There is an association between type 2 diabetes and major depressive disorder, anxiety and schizophrenia, thus there is a need for greater understanding of the relationship between GDM and mental illness. This review suggests that there is a bidirectional and complex relationship between antenatal depression, gestational diabetes and postpartum depression. The combined effect of both a history of depression and gestational diabetes significantly increases the risk of postpartum depression. There is an association between severe mental illness and GDM; however, it is strongly mediated by antipsychotic medications and psychosocial factors, in addition to the disease itself. Medication has a major role in treating mental illness during pregnancy and is not directly linked with GDM in either depression or psychosis. Health-care providers should be mindful of the association between GDM and mental illness to appropriately screen and treat both disorders.

Cycling reduces blood glucose excursions after an oral glucose tolerance test in pregnant women: a randomized crossover trial

The aim of this study was to evaluate the effect of an acute bout of cycling immediately after oral glucose intake on glucose metabolism in pregnant women at risk for gestational diabetes mellitus (GDM). Fifteen pregnant women with BMI ≥ 27 kg/m² were enrolled in a randomized crossover controlled study and underwent two oral glucose tolerance tests (OGTTs) ingesting 75 g of glucose followed by either 20 min of stationary cycling at moderate intensity (65%-75% maximal heart rate) or rest. Using continuous glucose monitors, glucose was measured up to 48 h after the OGTT. Glucose, insulin, and C-peptide were determined at baseline and after 1 and 2 h. One hour after glucose intake, mean blood glucose was significantly lower after cycling compared with rest (p = 0.002). Similarly, mean glucose peak level was significantly lower after cycling compared with after rest (p = 0.039). Lower levels of insulin and C-peptide were observed after 1 h (p < 0.01). Differences in glucose measurements after 2 h and up to 48 h were not statistically different. We found that 20 min of cycling at moderate intensity after glucose intake reduced blood glucose excursions in pregnant women at risk for GDM. ClinicalTrials.gov Identifier: NCT03644238. Novelty Bullets In pregnant women, we found that cycling after glucose intake resulted in significantly lower glucose levels compared with rest. The exercise intervention studied is feasible for pregnant women and could be readily used to reduce glucose excursions.

Culturally Tailored Resources for South Asian Immigrant Women With Gestational Diabetes: Do They Work and What's Missing? A Qualitative Study

OBJECTIVES

Gestational diabetes mellitus (GDM) increases the risk of pregnancy complications. South Asian immigrant women have among the highest rates of GDM in Canada and they also have the highest lifelong risk of developing type 2 diabetes after a GDM pregnancy. Diabetes Canada has been developing diabetes education material that accounts for the cultural preferences of South Asians. However, there is uncertainty to whether South Asian immigrants are aware of these resources or trust them, or if other factors influence their uptake of advice.

METHODS

In this study, we conducted qualitative interviews to explore, among South Asian immigrant women with GDM: 1) their awareness of diabetes education resources, 2) their attitudes toward information from different resources and varying health-care providers and 3) their barriers and facilitators for GDM management recommendations. Gender theory is embedded in this study, as culturally specific gender roles regarding motherhood have been shown to be important to South Asian immigrant women and their perceptions of health.

RESULTS

There was an emergence of 3 main themes. First, awareness of culturally tailored educational resources is low. Second, there is an overabundance of GDM management information, which leads to variability among participants of how they rank accuracy of informational sources. Finally, there is a gender role reversal present, where women are being taken care of by their families instead of being the providers of care.

CONCLUSIONS

These results indicate that better dissemination strategies for GDM educational material are needed for health-care providers and patients, and may require additional consideration of family involvement during GDM education sessions.

Characteristics of Women With Gestational Diabetes From Non-Caucasian Compared With Caucasian Ethnic Groups

OBJECTIVES

Short- and long-term outcomes in women after gestational diabetes mellitus (GDM) vary by ethnicity. Understanding differences in baseline diabetes risk factors is important for informing choice of risk-reducing interventions. We aimed to compare maternal and pregnancy-related characteristics in Caucasian and non-Caucasian women with GDM.

METHODS

Using a large multicentre Canadian cohort of women diagnosed with GDM and recruited between 2009 and 2013, we compared demographic, clinical and behavioural characteristics in women with GDM across 7 ethnic groups. Data were obtained from chart reviews and surveys, and logistic and linear regression models were used to compare binary and continuous variables, respectively, between Caucasian and non-Caucasian ethnic groups.

RESULTS

Of the 1,332 women with GDM, 911 were eligible for inclusion. Of these, 41.4% were white Caucasian, 17.1% were South Asian, 18.4% were East Asian, 5.8% were black, 8.8% were Filipina, 5.2% were Middle Eastern and 3.3% were Hispanic. Non-Caucasian women were diagnosed with GDM at a younger age and were more likely to have a family history of diabetes compared with Caucasian women. With the exception of East Asians, non-Caucasian women were more likely to be overweight using ethnicity-specific body mass index cutoffs and have higher oral glucose tolerance test values than Caucasian women. Prepregnancy smoking and alcohol consumption prevalence were highest in Caucasian women.

CONCLUSIONS

Several important ethnicity-specific differences in clinical and behavioural characteristics of women with GDM were identified. These differences need to be considered when offering interventions for reducing risk of adverse perinatal outcomes and subsequent type 2 diabetes.

The Avoiding Diabetes After Pregnancy Trial in Moms Program: Feasibility of a Diabetes Prevention Program for Women With Recent Gestational Diabetes Mellitus

OBJECTIVE

Our aim in this study was to evaluate the feasibility of a home-based diabetes prevention program, delivered by interdisciplinary certified diabetes educators (CDEs), and customized for postpartum women with recent gestational diabetes mellitus (GDM).

METHODS

This pilot randomized trial recruited women with GDM from 24 to 40 weeks gestation from 4 centres, and trained 10 CDEs in behaviour coaching, physical activity (PA) and low glycemic index education. Women were randomized after 3 months postpartum to standard care (1 visit) or 1 of 3 24-week coaching interventions (1 visit and 12 telephone calls): i) PA and diet, ii) PA only or iii) diet only. Feasibility outcomes included recruitment, retention, adherence and satisfaction.

RESULTS

Of 1,342 eligible patients, 392 were actively invited (29.3%) and 227 (16.9%) consented. Of these, 149 (65.6%) were randomized postpartum, of whom 131 (87.9%) started the program and 105 (70.5%) attended the final assessment. Intervention arm participants completed a median 75% (interquartile range, 50% to 92%) of telephone calls. Visit and call duration were a mean 71.4 (standard deviation, 13.8) and 18.1 (standard deviation, 6.5) minutes, respectively. Participants reported excellent/very good satisfaction 73% of the time, and 87% would recommend the program to others.

CONCLUSIONS

A home-based diabetes prevention program customized for postpartum women with GDM can be feasibly delivered by CDEs, and it is associated with >70% retention, adherence and satisfaction.

Perinatal Outcomes Among Different Asian Groups With Gestational Diabetes Mellitus in Ontario: A Cohort Study

OBJECTIVE

The aim of this study was to determine whether perinatal outcomes differ between Caucasian and Asian subgroups of women with gestational diabetes mellitus (GDM) through use of standard vs ethnicity-specific birthweight curves.

METHODS

This retrospective cohort study included 537 women with GDM, within the ethnically diverse province of Ontario, Canada. Study outcomes included large-for-gestational-age (LGA) and small-for-gestational-age (SGA) birthweights in newborns of women from prevalent Asian ethnic groups compared with newborns of Caucasian women. Odds ratios were adjusted for maternal age, parity, prepregnancy body mass index, gestational weight gain and insulin use in pregnancy.

RESULTS

Of the 537 women participing in the study, 228 (35.8%) were Caucasian, 109 (17.1%) South Asian, 141 (22.1%) East Asian and 59 (9.3%) Filipino. Using standard birthweight curves, compared with Caucasian women, the risk of LGA was lower among South Asian (adjusted odds ratio [aOR], 0.065; 95% confidence interval [CI], 0.01 to 0.49) and East Asian (aOR, 0.36; 95% CI, 0.14 to 0.95) women. The aOR for SGA was notably higher among South Asian women (aOR, 2.96; 95% CI, 1.24 to 7.09). Significant effects were not seen among Filipino women. Use of ethnicity-specific birthweight curves largely attenuated these associations, except for LGA in South Asian mothers (aOR, 0.27; 95% CI, 0.09 to 0.81).

CONCLUSION

South Asian women with GDM are at lower risk of having an LGA newborn, even after accounting for maternal risk factors or the use of an ethnicity-specific birthweight curve.

Serum Ferritin and Glucose Homeostasis in Women With Recent Gestational Diabetes

OBJECTIVES

Serum markers of iron storage have been linked to type 2 diabetes; however, the mechanism underlying this association is unclear. In pregnancy, increased serum ferritin has been reported in women with gestational diabetes (GDM), a patient population at high risk of future type 2 diabetes. However, in the years after pregnancy, it is not known if ferritin relates to their diabetes risk or the pathophysiologic determinants thereof (insulin sensitivity and beta-cell function). Therefore, we sought to characterize the relationship between ferritin and glucose homeostasis in the early postpartum years in women with and without recent GDM.

METHODS

At both 1 and 3 years postpartum, 340 women (105 with recent GDM) underwent serum ferritin measurement and an oral glucose tolerance test that enabled assessment of insulin sensitivity and/or resistance (Matsuda index and Homeostasis Model Assessment [HOMA-IR]), beta-cell function (Insulin Secretion-Sensitivity Index-2 and insulinogenic index/HOMA-IR) and glucose tolerance.

RESULTS

Serum ferritin did not differ between women who had GDM and their peers at either 1 or 3 years postpartum. Baseline-adjusted change in ferritin between 1 and 3 years correlated with the concomitant change in C-reactive protein (r=0.21, p=0.0002) but was not associated with measures of insulin sensitivity and/or resistance, beta-cell function or glycemia. On adjusted analyses, neither baseline ferritin nor its change from 1 to 3 years was independently associated with any of the following metabolic outcomes at 3-years postpartum: Matsuda index, HOMA-IR, Insulin Secretion-Sensitivity Index-2, insulinogenic index/HOMA-IR, fasting glucose, 2-h glucose or glucose intolerance.

CONCLUSIONS

Serum ferritin is not associated with glucose homeostasis in the early years after a GDM pregnancy.

Sex differences in the developmental origins of cardiometabolic disease following exposure to maternal obesity and gestational diabetes 1

Over the past 30 years, the worldwide prevalence of obesity has nearly doubled. In addition, more and more women in their child-bearing years are overweight or obese, which increases the risk of gestational diabetes mellitus (GDM). It is increasingly accepted by the scientific community that early life exposure to environmental stress influences the long-term health of an individual, which has been termed the Developmental Origins of Health and Disease theory. Evidence from human cohorts and epidemiological and animal studies has shown that maternal obesity and GDM condition the offspring for cardiometabolic disease development. These effects are most likely regulated by epigenetic mechanisms; however, biological sex is an important factor in defining the risk of the development of several metabolic health disorders. The aim of this review is to describe the current evidence from human cohort and animal model studies that implicates sex differences in the developmental origins of cardiometabolic disease following exposure to maternal obesity and GDM. In addition, this review addresses the potential mechanisms involved in these sex differences. In many studies, sex is ignored as an important variable in disease development; however, the results presented in this review highlight important differences between sexes in the developmental programming of biological responses to exposures during the fetal stage. This knowledge will ultimately help in the development of effective therapeutic strategies for the treatment of cardiometabolic diseases that exhibit sexual dimorphism.

Magnesium-zinc-calcium-vitamin D co-supplementation improves glycemic control and markers of cardiometabolic risk in gestational diabetes: a randomized, double-blind, placebo-controlled trial

To the best our knowledge, data on the effects of magnesium-zinc-calcium-vitamin D co-supplementation on glycemic control and markers of cardiometabolic risk in gestational diabetes mellitus (GDM) are scarce. The purpose of this study was to establish the effects of magnesium-zinc-calcium-vitamin D co-supplementation on glycemic control and markers of cardiometabolic risk of GDM patients. Sixty patients with GDM, aged 18-40 years, were randomized into 2 groups to intake either magnesium-zinc-calcium-vitamin D co-supplements or placebo (n = 30 each group) for 6 weeks in a randomized, double-blind, placebo-controlled trial. Fasting blood samples were taken at baseline and week 6 to quantify related markers. After the 6-week intervention, compared with the placebo, magnesium-zinc-calcium-vitamin D co-supplementation resulted in significant reductions in fasting plasma glucose (-0.37 ± 0.09 vs. +0.01 ± 0.09 mmol/L, P = 0.003), serum insulin levels (-21.0 ± 4.8 vs. +7.2 ± 4.8 pmol/L, P < 0.001), homeostatic model of assessment for insulin resistance (-1.0 ± 1.1 vs. +0.3 ± 1.3, P < 0.001), and a significant increase in quantitative insulin sensitivity check index (+0.02 ± 0.03 vs. -0.002 ± 0.03, P = 0.003). In addition, magnesium-zinc-calcium-vitamin D co-supplementation significantly decreased serum triglycerides (-0.25 ± 0.10 vs. +0.34 ± 0.10 mmol/L, P = 0.001) and very-low-density-cholesterol concentrations (-0.11 ± 0.04 vs. +0.15 ± 0.04 mmol/L, P = 0.001) compared with the placebo. Overall, the results of this study demonstrated that magnesium-zinc-calcium-vitamin D co-supplementation for 6 weeks among patients with GDM had beneficial effects on glycemic control and few markers of cardiometabolic risk.

Prevalence, predictors and challenges of gestational diabetes mellitus screening among pregnant women in northern Tanzania

OBJECTIVES

To determine the prevalence and predictors of gestational diabetes mellitus (GDM) as well as acceptability of returning for glucose tolerance testing among pregnant women in Moshi municipality, northern Tanzania.

METHODS

Cross-sectional study from October 2015 to April 2016 among women with gestation age of 24-28 weeks of pregnancy attending at Kilimanjaro Christian Medical Centre (KCMC) referral hospital, Majengo and Pasua Health Centres. Women were interviewed and requested to return the next day (window within a month, depending on gestational age) for fasting plasma glucose (FPG) testing, followed immediately by a 75 g oral glucose tolerance test (OGTT). GDM was diagnosed using the 2013 WHO criteria. Logistic regression was conducted to reveal independent predictors for GDM.

RESULTS

Of 433 interviewed women, 100 (23%) did not return for FPG and OGTT testing. The prevalence of GDM among the 333 screened women was 19.5%, and 3% had diabetes in pregnancy (DIP). GDM was significantly associated with age ≥35 years (adjusted OR 6.75), pre-pregnancy obesity (AOR 2.22) and history of abortion (AOR 2.36).

CONCLUSION

Prevalence of GDM is high in Moshi. We recommend introduction of routine screening for hyperglycaemia during pregnancy along with strategies for follow-up to prevent long-term effects of GDM and DIP in women and their children.

Population-Level Outcomes with a 2-Step Approach for Gestational Diabetes Screening and Diagnosis

OBJECTIVES

To examine outcomes associated with alternative glucose thresholds in a 2-step approach for screening and diagnosing gestational diabetes mellitus (GDM).

METHODS

We studied 178,527 pregnancies between 2008 and 2012 in Alberta, Canada. They were categorized retrospectively as normal 50 g screen (n=144,191); normal 75 g oral glucose tolerance test (OGTT) (n=21,248); abnormal at glucose thresholds suggested by the International Association of Diabetes and Pregnancy Group (IADPSG) (HAPO 1.75, n=4308); abnormal at glucose thresholds associated with an odds ratio of 2.0 for adverse events in the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study. This latter group, which would have been treated for GDM based on customary care, was further divided into those with 1 (HAPO 2-1 n=5528) or 2 or more abnormal glucose values (HAPO 2-2 n=3252). Main outcomes were large for gestational age (LGA), induced labour and Cesarean-section rates.

RESULTS

LGA rates were 8.2%, 10.5%, 14.2%, 11.8% and 16.5% among normal 50 g, normal 75 g OGTT, HAPO 1.75, HAPO 2-1, and HAPO 2-2 groups, respectively. Labour induction and caesarean-section rates were 29.6% and 36.2% in the IADPSG, 38.2% and 36.8% in the HAPO 2-1 group, and 42.3% and 41.1% in the HAPO 2-2 groups, respectively. Excessive maternal weight (≥91 kg) was associated with a higher risk for all adverse outcomes.

CONCLUSIONS

The 2-step approach effectively identifies pregnancies at low risk for adverse outcomes. Labelling influences induction practice. Any glucose intolerance increases risk for adverse outcomes, and pregnancies with highest (2 or higher) abnormal glucose values remain at greatest risk. Further research is needed to determine whether glycemic thresholds for GDM diagnosis should incorporate information about maternal weight.

A Randomized Controlled Clinical Trial Investigating the Effects of Omega-3 Fatty Acids and Vitamin E Co-Supplementation on Biomarkers of Oxidative Stress, Inflammation and Pregnancy Outcomes in Gestational Diabetes

OBJECTIVES

Limited data are available for assessing the effects of omega-3 fatty acids and vitamin E co-supplementation on metabolic profiles and pregnancy outcomes in gestational diabetes (GDM). This study was designed to determine the effects of omega-3 fatty acids and vitamin E co-supplementation on biomarkers of oxidative stress, inflammation and pregnancy outcomes in women with GDM.

METHODS

This randomized, double-blind, placebo-controlled clinical trial was conducted in 60 patients with GDM who were not taking oral hypoglycemic agents. Patients were randomly allocated to intake either 1000 mg omega-3 fatty acids from flaxseed oil plus 400 IU vitamin E supplements (n=30) or placebo (n=30) for 6 weeks. Fasting blood samples were obtained from the women at the beginning of the study and after the 6-week intervention to quantify related markers.

RESULTS

After 6 weeks of intervention, omega-3 fatty acids and vitamin E co-supplementation, compared with the placebo, resulted in a significant rise in total antioxidant capacity (TAC) (+187.5±224.9 vs. -32.5±136.1 mmol/L; p<0.001); nitric oxide (NO) (+5.0±7.7 vs. -12.0±28.0 µmol/L; p=0.002) and a significant decrease in plasma malondialdehyde (MDA) concentrations (-0.1±0.9 vs. +0.6±1.4 µmol/L; p=0.03). Co-supplementation with omega-3 fatty acids and vitamin E showed no detectable changes in plasma glutathione and serum high-sensitivity C-reactive protein levels. Joint omega-3 fatty acids and vitamin E supplementation resulted in lower incidences of hyperbilirubinemia in newborns (10.3% vs. 33.3%; p=0.03).

CONCLUSIONS

Overall, omega-3 fatty acids and vitamin E co-supplementation for 6 weeks in women with GDM had beneficial effects on plasma TAC, MDA and NO and on the incidence of the newborns' hyperbilirubinemia.

High Frequency of Pre-Existing Type 2 Diabetes in a Series of Pregnant Women Referred for "Gestational Diabetes" in a Large Canadian Indigenous Community

We examined the referral processes and true diagnostic classifications for diabetes complicating pregnancy in a series of 62 pregnant women consecutively referred to a diabetes education and treatment centre in a large Indigenous community in Alberta, Canada. The referrals were made over a 5-year period (2010 to 2015). The main findings of this analysis were the high frequency (38.7%) of pre-existing type 2 diabetes and previously undiagnosed or unrecognized overt diabetes and the deficiencies in early testing and recognition.

Are There Benefits for Gestational Diabetes Mellitus in Treating Lower Levels of Hyperglycemia Than Standard Recommendations?

OBJECTIVES

The new International Association of Diabetes and Pregnancy Study Groups (IADPSG) recommendations for diagnosis of gestational diabetes mellitus (GDM) are generating discussion regarding their universal adoption. Our centre is currently using stricter GDM diagnostic criteria than those proposed by the IADPSG. Evaluation of complication rates and their predictors in our cohort may provide insight for the care of this high-risk population. Therefore, we determined complication rates and identified antepartum maternal predictors of adverse outcomes in our cohort with mild GDM.

METHODS

A retrospective cohort study was performed between 2005 and 2011. It included women with and without GDM, which was diagnosed if fasting plasma glucose levels were 5.0 or above or 2-hour post 75 gram oral glucose tolerance test (OGTT) were 7.8 mmol/L or higher.

RESULTS

A total of 3712 women, with and without diabetes, were included. Rates of macrosomia and pre-eclampsia were significantly higher in the group with GDM but were lower than the rates usually reported. Macrosomia, the need for insulin therapy or caesarean section and postpartum glucose intolerance predictors included prepregnancy body mass index, excessive gestational weight gain and OGTT screening results, although no specific threshold was found.

CONCLUSIONS

This study provides insight into GDM-related complications rates and the benefits of intervention in a large cohort of women with levels of hyperglycemia lower than those currently recommended for diagnosis of GDM. These findings suggest a continuous association between adverse outcomes and maternal hyperglycemia and highlight the important role of maternal risk factors other than glycemic results in the development of pregnancy-related complications. Milder forms of hyperglycemia that would not be identified by IADPSG guidelines may benefit from treatment.

Gestational diabetes mellitus in sub-Saharan Africa: systematic review and metaregression on prevalence and risk factors

OBJECTIVE

We systematically reviewed publications on prevalence and risk factors for gestational diabetes mellitus (GDM) in the 47 countries of sub-Saharan Africa.

METHODS

We conducted a systematic search in PUBMED and reviewed articles published until June 2014 and searched the references of retrieved articles. We explored sources of heterogeneity among prevalence proportions with metaregression analysis.

RESULTS

Of 1069 articles retrieved 22 studies were included. Half were from West Africa, specifically Nigeria, five from South Africa and six from East and Central Africa. There were differences in screening methods and diagnosis criteria used, even between studies carried out in the same country and same time period. Metaregression analysis indicated high heterogeneity among the studies (I(2) = 100, P < 0.001), which could not be sufficiently explained by study setting, population, diagnostic criteria or time trend, although we observed a relatively higher prevalence in studies carried out after 2000 (5.1% vs. 3.2%), when women at risk were selected (6.5% vs. 3.8%) and when more current diagnostic criteria were used (5.1% vs. 4.2%). Associations with risk factors were reported in six studies. Significant risk factors reported in more than one study were overweight and/or obesity, family history for type 2 diabetes, previous stillbirth, previous macrosomic child and age >30 years.

CONCLUSIONS

There are few studies on prevalence and risk factors for GDM in Sub-Saharan Africa and heterogeneity is high. Prevalence was up to about 14% when high-risk women were studied. Preventive actions should be taken to reduce the short- and long-term complications related to GDM in Sub-Saharan Africa.

The subjective impact of a diagnosis of gestational diabetes among ethnically diverse pregnant women: a qualitative study

OBJECTIVE

Women diagnosed with gestational diabetes mellitus (GDM) require enhanced medical care, social support and health behaviour changes to reduce the complications of pregnancy and future adverse health outcomes. Little is known about how a GDM diagnosis positively and negatively impacts women, especially those of diverse ethnic backgrounds. This qualitative study sought to gain insight into the reactions and experiences of multiethnic women diagnosed with GDM.

METHODS

A qualitative descriptive approach was used to analyze semistructured telephone interviews conducted with 19 pregnant women of diverse backgrounds who were diagnosed with GDM. Interviews were recorded and transcribed and then coded and analyzed using content analysis.

RESULTS

This study identified 2 main themes and several subthemes. First, women reported many negative effects of a GDM diagnosis, including heightened pressure to fulfill multiple roles, financial impact, and a disconnect between diabetes-prevention recommendations and their cultural practices. Second, a GDM diagnosis also had positive effects on many women. Women indicated being motivated to make health behaviour changes after a GDM diagnosis and viewed it as a wake-up call to modify their lifestyles.

CONCLUSIONS

To help pregnant women with self-management of gestational diabetes, healthcare providers should pay greater attention to the adverse effects of GDM on women, including role expectations, cultural issues and financial barriers. Healthcare providers also need to focus on the positive effects and capitalize on women's motivation to make lifestyle changes to reduce their future risk for diabetes.

Osteocalcin is higher across pregnancy in Caucasian women with gestational diabetes mellitus

OBJECTIVE

The purpose of this study was to investigate circulating concentrations of osteocalcin, a bone-derived protein, while accounting for 25-hydroxyvitamin D (25(OH)D) throughout pregnancy, and whether early gestation concentrations and changes in osteocalcin predict the subsequent diagnosis of gestational diabetes mellitus (GDM).

METHODS

This was a nested case-control study involving 48 GDM and 48 control pregnant Caucasian women (matched for age, season of conception, pre-pregnancy body mass index and pregnancy length). Maternal serum osteocalcin was measured by enzyme-linked immunosorbent assay and 25(OH)D by chemiluminescence throughout pregnancy (11-13 weeks, 24-28 weeks and predelivery). Differences between groups were compared by mixed model analysis of variance. Predictors of diagnosis of GDM were explored using generalized estimating equation models. Neonatal general health outcomes were also compared between groups.

RESULTS

Serum osteocalcin was higher across pregnancy (p=0.006) in women with GDM vs. controls, whereas serum 25(OH)D was not different (p=0.80). Both biomarkers increased with time across pregnancy (p<0.0001). However, serum osteocalcin during early pregnancy and changes in its concentration from early to mid gestation did not predict the development of GDM. There were no significant differences in anthropometry and APGAR (appearance, pulse, grimace, activity, respiration) scores in neonates of controls and cases.

CONCLUSIONS

Serum osteocalcin is elevated in Caucasian women with GDM throughout pregnancy, but was not predictive of the onset of GDM. Larger trials evaluating the role of osteocalcin and the development of GDM appear warranted.

Food choice decision-making by women with gestational diabetes

OBJECTIVE

To enhance the dietary education presented to women with gestational diabetes (GDM) by exploring the reasons and experiences that women with GDM reported in making their food-choice decisions after receipt of dietary education from a healthcare professional.

METHODS

Food Choice Map (FCM) semi-structured in-depth interviews were conducted with 30 women with GDM living in the Winnipeg area during their pregnancies. Verbatim transcripts were generated from the interviews. A constant comparative method was used to generate common themes to answer research inquiries.

RESULTS

Personal food preferences, hunger and cravings were the main factors affecting food choice decision-making in women with GDM. Although the information from healthcare professionals was 1 factor that affected food choice decision-making for most of the participants, more than half of the women, including all the women who were on insulin, reported difficulties in quick adaptation to dietary management in a limited time period. Information from other sources such as family members, friends, and internet were used to cope with the adaptation. These difficulties led to a sense of decreased control of GDM and were accompanied by frustration, especially for women taking insulin.

CONCLUSIONS

Food choice decision-making varied for this group of women with GDM. Knowledge and information aided in making healthy food choices and in portion control. However, balancing individual needs and blood glucose control in a short time period was felt to be difficult and created frustration. The findings suggested that dietary consultation needs to be personalized and to be time sensitive to promote confidence in self-control.